Body posture in women after mastectomy and its changes as a result of rehabilitation
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BodySciences
· Advances in Medical posture in· women
Vol. 51 after
· 2006mastectomy
· and its changes as a result of rehabilitation 287
Body posture in women after mastectomy
and its changes as a result of rehabilitation
Rostkowska E 1*, Bąk M 2, Samborski W 3
1
University School of Physical Education in Poznań, Clinic for Physiotherapy, Rheumatology and Rehabilitation, University of Medical Sciences, Poznań, Poland
2
Higher Vocational State School in Leszno, Poland
3
Clinic for Physiotherapy, Rheumatology and Rehabilitation, University of Medical Sciences, Poznań, Poland
Abstract Introduction
Purpose: The aim of the study is: 1) to analyse selected Mastectomy is an operation which causes many changes
features of body posture in women after mastectomy, 2) to com- in a woman’s body. Its consequence are, among other things,
pare them with body posture of healthy women, 3) to determine lymphatic oedemas, limitation of movements and strength of the
the effect of rehabilitation physical exercises on the changes in upper limb of the patient, experiences in the emotional sphere,
body posture in women after mastectomy. difficulties related to the postoperative scar and the results of
Material and methods: The research material consisted supplementing treatment such a radiotherapy or chemotherapy.
of 85 women after mastectomy examined once, including 40 Significant complications after mastectomy are changes in body
of them who were additionally examined twice at six-monthly posture caused both by disorders in body static as a result of
intervals. Moreover, a group of 20 women was isolated who amputation and limitation of movements and soreness of the
regularly attended rehabilitation classes for a period of one spine.
year in question. A comparative group was a group of 85 healthy The problem of changes in body posture, as a result of
women. The examinations were performed using photogramet- mastectomy is not well known. It seldom appears in scientific
ric assessment of body posture. literature. It is, however, an important problem, both from
Results: Distinct adverse changes in body posture of the point of view of medical and psychological rehabilitation.
women after mastectomy in comparison with healthy women Incorrect body posture may cause other somatic anomalies. For
were found, manifested mainly in asymmetry of trunk and shoul- the patients good-looks related to body posture is the basis for
der girdle and greater forward leaning of the trunk. Significant better well-being [1,2].
relationship was indicated between the operation of mastectomy Thus physicians, psychologists and patients consider mas-
and the asymmetry of position of scapulas. tectomy as both physical and psychological problem. Among
Conclusions: When comparing the changes in the features physical impairments special attention is paid in the literature
of body posture in the group of women who exercised regularly to limitations in the shoulder joint, suggesting exercise in water
with other women for the period of one year it was found that and swimming as effective therapy [3]. Also Reksidler [4] reco-
a positive effect of regular rehabilitation was keeping the angle mmends exercises mainly in water as successful both psychic and
of body inclination on the same level and improvement in trunk physical therapy. On the other hand Hahn [5] suggests ski sport
symmetry, position of scapulas and shoulder girdle. as effective form of therapy, bringing back self-satisfaction and
diminishing depression after mastectomy.
Key words: mastectomy, posture, rehabilitation, exercise Another argument for the physical activity recommended
therapy. to women after mastectomy is based on the research conducted
in women undergoing chemotherapy. In eight weeks after the
* CORRESPONDING AUTHOR: surgery marching on an exercise track followed by the measure-
University School of Physical Education in Poznań ments of physiological parameters were performed. The results
Clinic for Physiotherapy, Rheumatology and Rehabilitation
University of Medical Sciences showed that even if the exercises caused fatigue on the same
Droga Dębińska 10C, 61-555 Poznań, Poland day in comparison to the days without exercise, there was no
Tel: +48 61 8355423; +48 61 8228723 cumulative effect [6].
e-mail: jaroe8@wp.pl (Elbieta Rostkowska)
Lymphatic oedema and its consequences are also a problem
Received 19.09.2005 Accepted 20.03.2006 in women who underwent mastectomy. As Schunemann et al.288 Rostkowska E, et al.
Table 1. Characteristics of the group of women after mastectomy (group A) on the first examination, the only one for this group
Characteristics of subjects (N=85) min-max SD v (%)
Age of subjects (years) 54.6 35-79 9.6 17.6
Operation age (years) 51.4 34-79 10.4 20.3
Time from operation (years) 3.4 0-14 4.02 117.5
Weight (kg) 68.9 49- 98 12.9 18.7
Height (cm) 161.6 150-176 5.6 3.5
Table 2. Characteristics of the comparative group of healthy women (group B)
Characteristics of subjects (N=85) min-max SD v (%)
Age of subjects (years) 51.5 42-60 4.3 8.4
Height (cm) 164.4 150-178 5.9 3.6
showed in their study [7] among 5 868 women after mastectomy Material and methods
in 1 405 lymphatic oedema was observed (assessed by the
increase of two centimeters of the operated limb’s circumfer- The following basic groups of subjects were selected for the
ence). Physical activity is a part of antioedematous therapy. analysis:
According to many authors as Damm [8], Schulz et al. • group A – 85 women after mastectomy (Tab. 1),
[9] and Munstedt et al. [10] motion and positive effect on the • group B – 85 healthy women (Tab. 2).
psychic should be stressed in the therapy of women after mastec- The groups of these sizes were examined once. Fourty
tomy, teaching them how to lead active and healthy lives. women from group A were additionally examined twice at
A question of trunk asymmetry in the frontal plane in women six-monthly intervals. In total they were examined three times;
after mastectomy was the concern of Dobosz et al. [11,12]. They in this way group C was formed. Some of them, 20 to be exact,
found a frequent asymmetry relating mainly to the position of systematically attended rehabilitation classes. The remaining 20
scapulas and shoulders. However, no author has ever analysed took part in rehabilitation unsystematically or did not attend this
in detail the changes in body posture caused by mastectomy, in type of classes at all.
relation to the time which elapsed after the operation. Group C was divided into:
In Poland breast reconstruction is still performed rarely. • group Ce – 20 women after mastectomy systematically
Women usually obtain external breast prostheses in the form taking part in rehabilitation exercises,
of special underwear. The aim of using this kind of supplement • group Cn – 20 women after mastectomy exercising
of the missing tissue is, among other things, compensation of irregularly or not exercising at all.
changes in trunk static caused by mastectomy. Regular use of 24 of them underwent a left-sided operation, 15 a right-
external prosthesis is very important for the effectiveness of this sided one, and one underwent the operation on both sides.
method of compensation for a missing breast. It was found that The examinations were carried out using photogrametric
a regular use of external breast prosthesis involving also wearing assessment of body posture which is based on the use of Moire
it every night results in smaller changes in body posture [13]. topography [12,15,16]. This method involves taking measure-
Śliwiński [14] and Dobosz et al. [11] also paid attention to ments on the basis of computer photography of a subject’s body
significant changes in body posture and the change in the func- and the use of the phenomenon of moire pattern. Obtaining spa-
tion of spine in women after mastectomy. tial image is possible thanks to the device “projecting” lines on
However, the available literature does not offer en exhaus- the subject’s back which fall at various angles and are distorted.
tive comparative study of women after mastectomy and healthy The image is recorded and analysed by a computer programme.
women, with a large number of subjects and a comprehensive During the examinations the women were standing.
analysis of many features of body posture depending on the From numerous results of measurements and calculations
degree of involvement of the subject in rehabilitation. The (in frontal, sagittal and transverse planes) obtained as a result of
authors have undertaken such a study. photogrametric assessment of body posture the following were
selected for the analysis:
The aim of the study is: in the frontal plane
• the analysis of selected features of body posture in – trunk inclination angle (TIA) from the perpendicular in
women after mastectomy, degrees, that is an angle in frontal plane between the perpen-
• determining differences between body posture of dicular and the straight line going through points C7 – S1,
women after mastectomy and the posture of healthy women at – maximum deviation of the line of spinous processes from
a similar age, the perpendicular (UK) in mm,
• determining the effects of rehabilitation physical exer- – difference in distance of lower angles of scapulas from
cises on body posture in women after mastectomy. the spine (OL) in mm,Body posture in women after mastectomy and its changes as a result of rehabilitation 289
– difference in the height of lower angles of scapulas (UL) tomy exercises based on isotonic contraction and short isometric
in degrees, tension were mainly used. Apart from active exercises proper
– inclination angle of the line of shoulders from the level also active exercises without pressure (in suspension) were
(SLA) in degrees, used, as long as functional abilities of the women allowed it. In
in transverse plane, in degrees individual cases (with weakened muscles, significant limitations
– difference in depth of lower angles of scapulas (UB) of mobility, soreness in the shoulder girdle or other complica-
(assessment of twisting), tions) passive or led exercises were used. In exercises low posi-
– pelvis twist angle (PTA), tions were mainly used, since physical exercises in high position
in sagittal plane, in degrees (standing) are the greatest burden to the circulatory system, in
– trunk leaning angle (TLA), that is an angle between the particular its venous part. Low isolated positions force the sub-
perpendicular and the line C7 – S1 in the sagittal plane, jects to perform proper movements, and do not allow compen-
– angle that is an angle of inclination from the perpen- sating for a limited mobility of shoulder girdle with movement of
dicular of lumbosacral spine, neighbouring joints (for example using the spine).
– angle that is an angle of inclination from the perpen- Since in women after mastectomy the static and body sym-
dicular of thoracolumbar spine, metry are disturbed, scoliosis arises, kypholordosis is changed
– angle that is an angle of inclination from the perpen- [11-14,17], it is important to locate the place where effects on
dicular of upper thoracic section, the spine are exerted according to the steering rule. Control
– angle that is the total of , , and angles. from above (of upper limbs) and from below (lower limbs) is
Additionally, results of measurements and calculations of used. In breathing exercises special attention is paid to breathing
such features as pelvis inclination angle (PIA), thoracic kyphosis route – upper-costal, diaphragmatic and mixed) and to teaching
angle (TKA), lumbar lordosis angle (LLA) and the ratio of the correct breathing rhythm. The aim of breathing exercises is to
depth of thoracic kyphosis to its length (TKR) were analysed. improve pulmonary ventilation after the operation, gradual
The normality of the distribution of analysed features of stretching of the scar and pressure on the cistern of chyle and
body posture was examined. Both normal distributions of the abdominal part of thoracic duct (squeezing the lymph out of
examined features and distributions not in line with normal them towards the head).
distribution were found. For this reason in statistical analysis During therapeutic rehabilitation educational effects were
nonparametric tests were used. In tables where results of considered relating to the patient’s behaviour at home, using
examinations with a distribution non-compliant with a normal antioedematous prophylaxis and making women realise the
distribution were presented, apart from arithmetic mean also significance of physical activity in the prevention of secondary
the median and quartiles were shown. malignant disease.
The relation of each of the examined features to basic
parameters was examined such as a women’s age at the time
of examination, a woman’s age at the time of operation, time Results
which elapsed from the operation in years, side of amputation
(left, right), regularity of rehabilitation, using external breast Trunk inclination angle (TIA) informs about the inclina-
prosthesis at night, weight and height. tion of the trunk to the left or to the right in the frontal plane.
The percentages of results within the norm and with a slight For 85 women after mastectomy it varied from 0.0 to 5.2 degrees
and significant deviation from the norm were specified. ( =1.53°, med=1.2°). For 67 of them the trunk was deviated
to the left, for 17 to the right, for one it was vertical. In healthy
Methodology of rehabilitation exercises women 66 left deviations, 13 right deviations and 6 cases of
Women in the Ce group were regularly (twice a week) attend- vertical position of the trunk were noted. The results of these
ing rehabilitation classes in a gym. Motion activity lasted about 60 examinations indicate clearly that in approximately 78% of
minutes. The programme of therapeutic rehabilitation included: women, both healthy and after mastectomy, the trunk is devi-
• increasing or maintaining mobility of shoulder joint on ated to the left in the frontal plane.
the operated side, Deviations of TIA from the perpendicular which do not
• increasing or maintaining muscle strength of the upper exceed 1.5° were considered normal, those of 3° were considered
limb on the operated side, as slightly deviated from the norm, and those greater than 3° as
• correction of faulty posture which arose as a result of strongly deviating from the norm (Tab. 3).
amputation, For 85 women after mastectomy 60% of results were
• balancing the strength of postural muscles and develop- normal, 30.6% of results were slightly deviated from the norm
ing postural endurance, and 9.4% of results were significantly deviated from the norm.
• increasing the efficiency of respiratory system, Searching for a relation between TIA and basic parameters
• prevention of lymph stasis in the limb and in the area of listed in the “Methods” section only a relation between the
operation, direction of TIA (trunk deviated to the left or right) and the age
• improvement of physical efficiency and body fitness, of the subject during operation was found. Women operated at
• effect on the mind in order to achieve adaptation to an older age more frequently have their trunks deviated to the
changed living conditions. right: Spearman’s R=0.30 where p=0.006. This is not, however,
In the rehabilitation of the examined women after mastec- linked to the side of operation.290 Rostkowska E, et al.
Table 3. Size of TIA and its relation to normative values in healthy women and in women after mastectomy in three examinations (in
degrees)
TIA 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
1.24 1.74 1.37 1.42 1.84 1.83 1.74
min-max 0-3.6 0.3-3.4 0.3-3.3 0-3.1 0-0.4 0-4.3 0.4-3.7
SD 0.84 1.00 0.96 0.94 1.19 1.24 1.12
v (%) 67.90 57.50 70.20 66.30 64.60 67.80 64.30
% of results
Normal 63.50 55 50 50 60 45 50
slight deviation 32.90 40 45 30 30 35 25
large deviation 3.50 5 5 20 10 20 25
Table 4. Value of UK and its relation to normative values in healthy women and in women after mastectomy in three examinations
(mm)
UK 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
4.14 5.30 4.37 4.60 4.44 4.69 5.16
min-max 0-10.4 1.8-10.4 1.1-9.3 1.1-9.4 1.1-9.7 1.2-19.6 1.2-12.6
SD 2.1 0 2.7 0 2.1 0 2.5 0 2.4 0 3.9 0 3.20
v [%] 50.0 0 50.2 0 47.2 0 54.8 0 54.3 0 83.4 0 62.40
% of results
normal 70.6 0 55 70 60 65 75 55
slight deviation 28.2 0 35 30 40 35 20 40
large deviation 1.2 0 10 0 0 0 5 5
40 women after mastectomy who were examined three times Figure 1. Changes in TIA between the 1st and the 3rd
examination of women after mastectomy
were characterised by a greater value of TIA, thus a spine more
deviated to the side than healthy women. This adverse effect was 16
N
15
intensified for women not exercising regularly (Cn group).
In the group of non-exercising women more cases of dete-
rioration, that is increased TIA between the 1st and the 3rd 12
10
examination, was found (Fig. 1).
A maximum deviation of the line of spinous processes 8
TIA
8
from the perpendicular in the frontal plane (UK) informs about
the existence of scoliosis even in case of compensating for it and
4
ultimately vertical position of the spine. So there is a possibility
4
of a high value of UK with TIA equal to zero. 2
1
In 85 women after mastectomy (group A) the arithmetic
mean of UK was 5.0 mm (med 4.3, min-max: 1.1-12.1, Q1-Q3: 0
improvement no changes deterioration
3.1-6.5), and in healthy women 4.1 mm (Tab. 4). The values
of UK of up to 5 mm were considered as normal, those up to group Ce group Cn
10 mm as slightly deviated from the norm and those exceeding
10 mm as strongly deviated from the norm.
In group A 61.2% of UK were normal, 32.9% were slightly
deviated and 5.9% strongly deviated. The value of UK did not Th7 to Th12 or lumbar vertebra), and in younger women on the
differ in a statistically significant way between groups A and B. section Th1 to Th6. Such regularity was not found in group B. In
In group A value of UK was related to the use of an external group A there were 52 UK results to the left and 33 to the right.
breast prosthesis at night; the subjects who used them were Similarly in group B there were 50 UK to the left, 34 to the right
characterised by a lower UK (Spearman’s R=-0.23, p=0.030). and for one subject the spine was straight at the whole length.
The location of the spinous process most removed from the per- It can be said that similar to TIA though in smaller percentage,
pendicular on the length of the spine was related in group A only UK is more often directed to the left. No relation between the
to the age of a woman at the time of the examination (R=0.281, direction of UK and the side of operation was found.
p=0.0097). In women older at the time of the examination UK In women in Ce group a tendency to lowering of the UK was
was more frequently located on lower parts of the spine (section observed during exercises (Tab. 4) and in women in Cn groupBody posture in women after mastectomy and its changes as a result of rehabilitation 291
Figure 2. Number of subjects for whom improvement, Figure 3. Number of subjects in whom improvement,
deterioration or no change in UK was noted in three deterioration or no changes in OL were noted during three
examinations (between the 1st and the 3rd examination) examinations (between the 1st and 3rd examination)
12 12
N
N
11 11 11
10
9
8 8
7
6
UK
OL
5
4
4 4
3
2
1
0 0
improvement no changes deterioration improvement no changes deterioration
group Ce group Cn group Ce group Cn
Table 5. Value of OL and its relation to normative values in healthy women and in women after mastectomy in three examinations (mm)
OL 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
8.0 15.6 10.9 8.1 7.5 10.0 10.2
min-max 0.0-22.9 0-32.9 1.0-27.3 0-22.7 0-24.3 0.5-27.8 0.5-20.2
SD 5.5 9.1 7.2 6.8 6.4 7.4 5.2
v (%) 68.3 58.6 66.3 83.7 86.3 74.2 51.2
% of results
normal 62.3 25 50 75 70 65 35
slightly deviated 34.1 45 40 15 25 25 60
strongly deviated 3.5 30 10 10 5 10 5
– the increase of the UK value. These changes were not always In group C the level of OL is varied depending on the
statistically significant. research subgroup and time of examination (Tab. 5).
In group Ce during rehabilitation exercises a number of sub- In group Ce during rehabilitation an improvement in OL
jects for whom improvement in UK increased, and the number was observed in half of all subjects. This result was not analysed
of subjects for whom UK deteriorated, decreased. A reverse statistically due to the small number of patients in groups Ce
phenomenon was noted in group Cn (Fig. 2). and Cn, but for the practice of the motional rehabilitation such
The difference in distance between lower angles of improvement is highly important.
scapulas from the spine (OL) informs about the asymmetry of The difference in the height of lower angles of scapulas
position of scapulas in relation to the spine. In group A it does (UL) informs about asymmetry of scapulas in the frontal plane.
not show normal distribution. It reaches the arithmetic mean of In group A the distribution of results was not in line with normal
11.7 mm (med=10.2 mm, min-max: 0.0-33.5, Q1-Q3: 5.1-17.6). distribution. The arithmetic mean was 2.9°, and the median 1.7°
The values of OL up to 10 mm were considered as normal, up to (min-max: 0.0-10.7, Q1–Q3: 0.9-4.2). Slight but statistically sig-
20 mm as slightly exceeding the norm, and higher than 20 mm nificant relation between the side of amputation and the direc-
as strongly deviated from the norm. In the results of group A tion of asymmetry of scapula position was found (Spearman’s
48.2% of results were normal, 32.9% were slightly deviated and R=0.22, p=0.044). The scapula on the operated side is located
18.8% were strongly deviated (Fig. 3). higher. Mann-Whitney U test did not show a difference in UL
OL does not display a relation with any basic features. It between groups A and B. UL deviations and deviations of other
differs in a statistically significant way from group B to the dis- discussed features that are SLA and UB, which did not exceed
advantage of group A (value of Mann-Whitney U test, U=2 736 1.5° were considered as normal, those of 3o were considered as
where p=0.0063). In 53 women after mastectomy the right a slightly deviated from the norm and larger than 3o as strongly
scapula is further from the spine than the left one, in 2 both deviated from the norm.
scapulas are at the same distance from the spine, and in 30 the In group A 45.9% of normal results, 16.5% of results slightly
left scapula is further from the spine than the right one. These deviated from the norm and 37.6% results with a strong devia-
numbers are similar in group B (50, 4, 31, respectively). tion were found. Higher left angle of scapula was noted in 43292 Rostkowska E, et al.
Figure 4. Number of subjects for whom improvement, Figure 5. Number of subjects in whom improvement,
deterioration or no changes in UL were noted in three deterioration or no change in SLA was noted in three
examinations (between the 1st and the 3rd examination) examinations (between the 1st and the 3rd examination)
16 16
N
N
13
12
12 12 11
8
SLA
UL
8 8
6 6 6
5
4
4 3 4 3 3
0 0
improvement no changes deterioration improvement no changes deterioration
group Ce group Cn group Ce group Cn
Table 6. Value of UL and its relation to normative values in healthy women and in women after mastectomy in three examinations
(degrees)
UL 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
1.91 2.03 2.61 2.26 2.55 1.92 2.52
med 1.2 1.65 1.2 2.15 1.8 1.45 1.8
min-max 0-6.6 0-6.5 0-10.7 0-7.1 0-7.3 0-5.2 0-7.7
Q1 0.9 0.8 0.4 0.8 1.4 0.95 0.9
Q3 3.1 3.6 4.3 2.95 3.05 5.2 3.25
% of results
normal 55.3 45 55 40 25 55 35
slightly deviated 18.8 25 10 40 50 30 30
strongly deviated 25.9 30 35 20 25 15 35
Table 7. Value of SLA and its relation to normative values in healthy women and women after mastectomy in three examinations
(degrees)
SLA 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
0.91 1.52 1.41 1.33 1.29 1.22 1.42
min-max 0-3.7 0-3.0 0.4-5.1 0-2.7 0-4.5 0-3.5 0-5.7
SD 0.77 0.85 1.15 0.79 1.03 1.03 1.38
v (%) 84.7 56.0 81.5 59.4 79.8 84.4 97.3
% of results
normal 82.4 45 70 55 60 70 70
slightly deviated 15.3 55 20 45 35 20 20
strongly deviated 2.4 0 10 0 5 10 10
women in group A and 35 women in group B. Higher right angle der was higher for 40 women after mastectomy and 30 healthy
of scapula was found in 30 women after mastectomy and in 36 women. The right shoulder was higher for 41 women in group A
healthy women. Other women had both angles of scapulas at and 43 women in group B. For other subjects the shoulders were
the same level. level. In group A 58.8% of normal results, 32.9% of results with
In group Cn the value of UL was the least beneficial among slight deviation and 8.2% of results with a strong deviation were
all subjects (Tab. 6, Fig. 4). found. Mann-Whitney U test indicated a significant difference
Shoulder line angle (SLA) informs about deviations of the between SLA values in groups A and B (U=2 314, p=0.0000).
shoulder line from level in the frontal plane. No relations between the value and size of SLA and basic fea-
In group A it was characterised by a distribution not in line tures were found.
with Gauss’ curve. The arithmetic mean of SLA in group A was Healthy women were characterised by a lower average SLA
1.6° (med=1.3°, min-max 0-6.1, Q1-Q3 0.8-2.1). The left shoul- and a larger percentage of normal results or results with a slightBody posture in women after mastectomy and its changes as a result of rehabilitation 293
Table 8. Value of PTA and its relation to normative values in healthy women and in women after mastectomy in three examinations
(degrees)
PTA 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
2.69 3.9 3.2 4.1 3.3 5.4 3.8
min-max 0.0-15.2 0.0-21.5 0.0-7.1 0.0-16.7 0.0-9.1 0.0-16.3 0.0-17.2
med 2.2 3.1 3.4 3.3 2.7 4.4 2.1
Q1 0.8 1.2 1.3 1.5 1.0 2.7 1.2
Q3 3.9 4.6 4.8 5.0 4.5 6.4 5.2
% of results
normal 68.2 50 50 45 55 25 60
slightly deviated 23.5 35 35 35 30 45 20
strongly deviated 8.2 15 15 20 15 30 20
deviation than women after mastectomy. The largest number of Figure 6. Number of subjects for whom improvement,
deterioration or no changes in PTA were noted in three
subjects with a significant deviation of SLA from the norm was
examinations (between the 1st and 3rd examination)
in group C (Tab. 7, Fig. 5).
The difference in the value of SLA between healthy women 12
and group Ce was statistically significant in the first examination N
(Mann-Whitney U test, U=490, p=0.003). In the next examina-
9 9 9
tions it became insignificant, which would indicate the improve-
ment of this feature as a result of rehabilitation. 8
However, the assessment based on of shifting women to 6
PTA
another category in the period between the 1st and the 3rd exami- 5
nation did not display differences between groups Ce and Cn.
4
The difference in the depth of lower angles of scapulas
informing about their twisting (UB) very significantly differs 2
between groups A and B (Mann-Whitney U test, U=2 555.5,
p294 Rostkowska E, et al.
Table 9. Value of TLA and its relation to normative values in healthy women and in women after mastectomy in three examinations
(degrees)
TLA 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
2.7 2.2 3.0 2.3 2.5 3.2 3.0
min-max 0.0-7.1 0.2-4.5 0.0-6.2 0.0-6.7 0.4-6.1 0.3-5.7 0.0-10.2
SD 1.8 1.2 2.0 1.8 1.8 1.6 2.8
v (%) 65.7 53.8 68.7 76.7 73.0 49.9 94.1
% of results
normal 63.5 80 60 65 60 50 65
slightly deviated 30.6 20 25 30 35 50 25
strongly deviated 5.9 0 15 5 5 0 10
Table 10. Value of angle in healthy women and women after mastectomy in three examinations
angle 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
6.1 6.9 8.2 7.6 6.4 9.4 7.2
min-max 0.0-18.1 0.0-24.5 0.0-16.3 0.0-14.9 0.0-14.2 0.0-19.6 0.0-20.5
med 5.3 5.8 8.5 7.0 6.2 10.3 7.8
Q1 2.8 3.1 3.3 4.6 3.2 7.1 3.1
Q3 8.9 9.7 12.2 12.0 9.5 13.0 8.8
Accepting as the most correct posture the situation when Figure 7. Number of subjects in whom improvement,
points C7 and S1 are in one vertical line, the number of normal deterioration or no change in TLA was noted in three
examinations (between the 1st and the 3rd examination)
results and results beyond the norm was established. Forward or
backward deviation from the perpendicular up to 3o was consid- 12
N
11
ered as within norm, up to 6° as slight deviation and above 6o as
strong deviation from the norm. 9
In group A 58.8% of results were normal, 37.6% of results 8
8
displayed a slight deviation and 3.5% of results – a strong devia-
tion from the norm. In group B there were more results within
TLA
the norm (Tab. 9, Fig. 7). 5
4
Examining the relation between the time which elapsed from 4
3
the mastectomy and the direction of TLA (leaning backward or
forward) indicates that a recent operation is related to inclination
forward and an operation long time ago to backward leaning.
When observing the direction of changes in TLA in group 0
improvement no changes deterioration
C (leaning forward or backward as a result of regular rehabilita-
tion) ANOVA Friedman’s test and Kendall’s compatibility coef- group Ce group Cn
ficient were used. In group Ce slight but statistically significant
differentiation of this feature was noted in three examinations;
the arithmetic means increased gradually, that is the subjects
(group Ce) leaned forward more and more with each examina- of measurement of angle between groups A and B. The values
tion (Chi squared ANOVA=6.6, pBody posture in women after mastectomy and its changes as a result of rehabilitation 295
Table 11. Value of angle in healthy women and in women after mastectomy in three examinations
angle 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
9.7 10.3 10.0 9.0 10.8 7.9 9.9
min-max 1.8-17.5 5.3-15.1 3.3-17.4 2.0-16.5 3.4-17.0 0.6-12.1 -0.4-16.7
SD 3.5 2.7 3.5 3.5 3.7 3.0 4.9
v (%) 35.1 25.8 34.6 38.6 34.6 37.9 49.5
Table 12. Value of angle in healthy women and in women after mastectomy in three examinations
angle 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
15.8 16.4 17.5 19.6 17.6 19.9 17.7
min-max 2.2-30.8 10.3-24.5 4.1-29.1 8.6-29.3 6.6-24.2 8.2-27.4 9.1-30.1
SD 5.3 4.3 5.2 4.9 4.1 5.4 5.5
v (%) 33.4 26.3 29.5 25.0 23.3 27.3 30.8
Table 13. Value of angle in healthy women and in women after mastectomy in three examinations
angle 1st examination 2nd examination 3rd examination
Group B Ce Cn Ce Cn Ce Cn
31.6 33.5 35.7 36.1 34.8 37.2 35.0
min-max 17.2-49.8 24.7-57.1 22.6-52.0 24.5-51.2 25.2-41.4 19.0-55.7 20.4-45.2
SD 6.9 7.4 6.6 7.4 4.3 9.4 6.6
v (%) 21.9 22.0 18.4 20.5 12.5 25.3 18.8
healthy women. In group A its value was related to height in latter one named as TKR showed some interesting properties.
reverse relation (Spearman’s R=-0.35, p=0.001). A similar rela- The values of TKR differed in a statistically significant way
tion was noted in group B (R=-0.33, p=0.0024). In group Ce between groups A and B (group A =0.03, SD=0.016, group B
its value was systematically going down, and these changes are =0.05, SD=0.012, Student’s t -2.53, p296 Rostkowska E, et al.
– greater trunk inclination angle, – maintaining TIA on a stable level,
– greater symmetry of scapula position, – decrease that is improvement in UK, OL, SLA.
– higher position in the frontal plane of the scapula on the PTA is a feature which does not show improvement or even
operated side, shows deterioration in women after mastectomy who exercise
– much greater angle of shoulder line which means that regularly. Since features related to the position of scapulas and
shoulder are more deviated from the level in frontal plane, shoulder girdle improved during exercises it may be assumed
– much greater difference in the depth of lower scapula that this took place at a cost of compensation achieved by
angles, a change in the position of pelvis. This opinion should be, how-
– greater angle of pelvis twisting, ever, supported by a study of individual cases.
– greater forward leaning of the trunk, The increase in PTA in Ce group seems to be a negative
– greater total value of angles of spinal curvatures, effect of rehabilitation. If compensation is a result of anti-
– lower ration of the depth of thoracic kyphosis to its scoliosis exercises, more careful stabilisation of pelvis during
length and lower depth of thoracic kyphosis. Thus, greater for- all exercises affecting the spine, scapulas and shoulder girdle is
ward leaning of trunk in women after mastectomy is caused by needed. Their position should not be corrected at the costs of
a greater angle in them, compensation by twisting the pelvis. Thus, emphasis should be
– directly proportional relation between the value of placed on isolated positions during physical exercises.
angle and weight, It should be stressed that the groups Ce and Cn were not
– a tendency to increase of the angle and large interper- numerous, which negatively affected the statistical significance.
sonal changeability of the angle. And yet the results obtained three times when women from the
group Ce exercised regularly are of great value for the practice
These results are in agreement with the results of few papers of motional therapy.
published up to date and concerning this topic [5]. However, the The results of the examinations informing about the
presented results of the trunk leaning angle (TLA) measure- changes in spine angles ( , , and ) and its natural curvatures
ments differ in this article from what Dobosz et al. [6] presented (lordosis, kyphosis) are ambiguous. Women in group Ce during
in the paper presenting body posture of women after mastec- a year of exercises leaned forward more than group Cn where
tomy. Like us, other authors, have not found any link between smaller leaning was also noted. In any case this is not a positive
side of surgery and the direction of asymmetry of body posture phenomenon. Thus, more exercises of back muscles – the tho-
alterations. racic part (decreasing the angle) and exercises stretching the
The relation between the results of examinations of body chest should be introduced to rehabilitation.
posture and features called basic were not strong and did not
allow isolating one feature determining the body posture of
women after mastectomy. However, it was found statistically Conclusions
significant that:
– there is a slight, although statistically significant relation In the study great changes in body posture of women after
between the side of amputation and the direction of asymme- mastectomy were noted compared to healthy women at similar
try of position of scapulas; the scapula in the operated side is age. This phenomenon was so far only partly recognized [20];
higher, however, it was not described in detail. It should be consid-
– women operated at an older age more frequently have ered in what way the negative effects of mastectomy could
their trunks deviated to the right, and the right side of their be reduced. Hawro et al. [9] write about the significance of
pelvises is moved backwards, early, postoperation rehabilitation for the reduction of effects
– the location of the spinous process furthest deviated of mastectomy. The results of the studies are an argument for
from the perpendicular on the length of the spine was related in putting an emphasis on early, and then on long-term, continu-
group A with the age of a women at the time of the examination. ous rehabilitation. This may be a way to stop later irregularities.
In women older at the time of examination UK most frequently Starting rehabilitation too late can lead to changes which are
was located on lower sections of the spine (section Th7 to Th12 or difficult to reverse.
lumbar vertebra), and in younger women on section Th1 do Th6, Great changes in body posture are also an argument for wider
– recent operation is related to forward leaning of the introduction of breast reconstruction operations in Poland, since
trunk, and operation a long time ago with backward leaning of the use of breast implants gives better results in maintaining body
the trunk; it should be assumed that leaning of the trunk forward symmetry [14]. Though asymmetry may also take place with the
a short time after the operation is an analgesic and protective use of implant [14], its intensity is much smaller.
position which passes with time, Lymphatic oedema also contributes to the intensification of
– the value of UK in group A was related to the use of disorders in body posture [3]. Rehabilitation should always be
external breast prosthesis at night; the subjects who used it were combined with antioedematous prophylaxis.
characterised by a lower UK. Undoubtedly taking part in rehabilitation, apart from its
influence on somatic features of the subjects, has a very sig-
The comparison of the changes in features of body posture nificant positive effect on their minds [2]. This is an additional
in groups Ce and Cn allows us to note the following positive important argument for popularization of rehabilitation in
effects of rehabilitation in subjects who exercise regularly: women after mastectomy.Body posture in women after mastectomy and its changes as a result of rehabilitation 297
Future research on the motional rehabilitation of women 10. Munstedt K, Milch W, Reimer C. Epicutaneous breast forms
after mastectomy should head in two directions. First, the after mastectomy. Geburtshilfe und Frauenheilkunde, 1996; 65(1): 8-12.
11. Dobosz J, Malicka I, Woźniewski M, Skolimowski T, Barczyk K,
alterations in body posture should be monitored during regular Skolimowska B. Asymetria postawy ciała i czynność kręgosłupa u kobiet
physical exercises. There is an urgent need to work out an exact po mastektomii. Asymmetry of body posture and function of spine in
program of those exercises that improve particularly difficult women post radical mastectomy. Fizjoterapia, 1998; 6(3): 36-9.
12. Dobosz J, Woźniewski M, Malicka I. Ocena stopnia asymetrii
features in the body posture. Patients should also be protected tułowia w płaszczyźnie czołowej u kobiet operowanych z powodu raka
against compensatory changes. Another research topic is based sutka. Estimation of asymmetry in frontal plane in women post surgical
on observation of alterations in body posture and their preven- treatment due to breast cancer. Fizjoterapia, 1999; 7(1), 52-6.
13. Bąk M, Rostkowska E. Wpływ stosowania protezy piersi podczas
tion in those women on whom new surgical techniques, e.g. snu na postawę ciała u kobiet po mastektomii. The influence of using
breast reconstruction, were conducted. breast prosthesis during the night on the changes of body posture among
women after mastectomy. (In Polish, English summary) Fizjoterapia,
2000; 8, 4: 11-5.
14. Śliwiński Z. Ocena dysfunkcji ruchowych kręgosłupa u kobiet po
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